\ Special Exposure Cohort Petition U.S. Department of Health and Human Services 

under the Energy Employees Occupational Centers for Disease Control and Prevention 

illness Compensation Act National Institute for Occupational Safety and Health 1 A,-??- ,.- -- 37":: qr tn 93 ' &B Number 0920-0639 Expires: 05/31/2007 

Special Exposure Cohort Petition - Form A Page 1 of 2 

I Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose 

this number will not result in the denial of any right, benefit, or privilege to which you may be entitled. I I Instructions on Completing this Form: 

I You should use this petition form oniy if NIOSH has reported to you in writing that it cannot complete the 

dose reconstruction needed for your cancer claim. I All other petitioners should uw Petition Form B to submit a petition to NOSH. 

For Further Information: if you have questions about these instructions, please call the following NlOSH 

toll-free phone number and request to speak to someone in the Office of Compensation Analysis and 

Support about an SEC petition: 1-800-356-4674. 

A.l NlOSH Trackina Number (indicated on ail NIOSH correspondence): 

I A.2 Print Name offinergy Employee for whom tys claim was filed: I / . />---, 

~r.l~rs.1~~. First Name Middle Initial Gst Name /-- 

A.3 Social Security Number of Energy Employee for whom this claim was flled: 1 

I 

Print and sign yolir riame below to indicate that you are petitioning for HtIS to consider adding a class 

of employees to the Special Exposure Cohort that would include the employee indicated by the 

tracking number or name under entry 1 above. 

Print your name below: Sign your name below: . . , . , . . ', i; n~ ~ jJ ,/) f 

I First ~ame Middle initial Last Name First Name Middie Initial 'Last Name 

Once NIOSH receives this form. the U.S. Department of Health and Human Services will consider adding a 

class of employees to the Special Exposure Cohort. Your contact at NlOSH will be available to inform you of 

the progress of your petition. 

Send this form to: SEC Petition 

Office of Compensation Analysis and Support 

NlOSH 

4676 Columbia Parkway, MSC-47 

Cincinnati, OH 45226 

Name or Social Security Number of First Petiiioner: 
Public reporting burden for this collection of information is estimated to average 3 minutes per response, 

including time for reviewing instructions, gathering the information needed, and completing the form. If you 

have any comments regarding the burden estimate or any other aspect of this collection of information, 

including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton 

Road. MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this 

address. Completed petitions are to be submitted to NlOSH at the address provided in these instructions. 

Persons are not required to respond to the information collected on this form unless Rdisplays a currently 

valid OMB number. 

Prlvacy Act Advisement 

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 5 552a), you are hereby notified of the 

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 53 7384-7385) 

(EEOICPA) authorizes the President to designate additional classes of employees to be included in the 

Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the 

assistance of the National lnstitute for Occupational Safety (NIOSH), an Institute of the Centers for Disease 

Control and Prevention. Information obtained by NlOSH in connection with petitions for inciuding additional 

classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory 

Board on Radiation and Worker Health and HHS. 

Records containing identifiable information become part of an existing NlOSH system of records underthe 

Privacy Act, 09-20-147 "Occupational Health Epidemiological Studies and EEOICPA Program Records. 

HHSICDCINIOSH." These records are treated in a confidential manner, unless othedse compelled by law. 

Disclosures that NlOSH may need to make for the processing of your petition or other purposes are listed 

NlOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal 

agencies, other government or private entities and to private sector employers to permit these entities to 

retrieve records required by NIOSH; (b) identified w'besses as designated by NlOSH so that these 

individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors aSSi~ting ' 

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; 

(e) Federal, state and local agencies for law enforcement purposes; and (9 a Member of Congress or a 

Congressional staff member in response to a veriied inquiry. 

This notice applies to all forms and informational requests that you may receive from NIOSH in connection 

with the evaluation of an SEC petition. 

Use of the NlOSH petition forms (A and B) is voluntary but your provision of information required by these 

forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to 

provide required information may not be considered by HHS. 

Name or Social Sewrily Number of First Petitioner: - 
Special Exposure Cohort Petltlon U.S. Department of Health and Human Sewlces 

under the Energy Employees Occupational Centers for Disease Control and Preenson 

Illness Compensation Act National Institute fw Occupational Safety and Health 

OMB Number. 0920-0639 Expires: 05/31/2007 

Petitloner Authorization Form Page 2 of 2 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 3 minutes per response. 

including time for reviewing instwctions, gathering the information needed, and completing the form. If you 

have any comments regarding the burden estimate or any other aspect of this collection of information. 

including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clion 

Road, MS-E-11, Atlanta GA. 30333; AlTN:PRA 0920-0639. Do not send the completed petition form to this 

address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions. 

Persons are not required to respond to the information collected on this form unless it displays a currently 

valid OMB number. 

Use of this form is voluntary. Fallure to use this form will not result in the denial of any right, benefit, or 

privilege to which you may be entitled. 

Name or Social Security Number of First Petltiir: